A 48-year-old woman presents to dermatology with a complaint of hair loss. Distraught, she fears she’s “going bald.” This process began several months ago, when she noted a single area of involvement in the frontal scalp. There are now several asymptomatic areas, which have persisted despite the use of several products prescribed by her primary care provider: topical econazole, triamcinolone cream, and most recently, clobetasol foam. None of these has had any beneficial effect; her existing lesions have slowly expanded in size and number.

She denies any history of similar problems or of other skin diseases. In general, her health is quite good, with no joint pain, fever, or malaise. Prior to the onset of this condition, she took no prescription or OTC medications. There is no exposure to new pets or other animals, and no one else in her household is affected. She has been married for more than 25 years, in a mutually monogamous relationship.

Blood tests (complete blood count, thyroid, chemistry panel, and antinuclear antibody) have been done by her primary care provider. The results were all normal, shedding no light on the condition’s origins.

On examination, four distinct areas of hair loss are seen. They range in size from 3 to 6 cm, are roughly fusiform in shape, and are located from frontal to occipital scalp (all in the central quarter of her scalp). In each of these areas, the hair loss is complete, with a scarlike epithelial surface but no other disruption in the skin. Around the periphery of each lesion, there is a faint pinkish tinge. Other than alopecia, no other changes are palpated. There is no tenderness in the lesions and no palpable adenopathy in nodal locations of the head and neck.

ANSWER
The correct answer is to perform a biopsy (choice “d”). Although the other choices can be part of the workup for scalp conditions (eg, secondary syphilis, lupus, or fungal infection), the most logical step is to assess the basic histopathologic process. This would provide the clearest direction by revealing characteristic changes in the tissues. Starting an oral antibiotic, such as minocycline, might be a reasonable step if biopsy were not possible.

DISCUSSION
This is a typical case of “scarring alopecia,” a category of hair loss with a wide-ranging differential diagnosis. Included in it would be lymphoma-associated perifollicular mucinosis, discoid lupus, lichen planopilaris (lichen planus affecting the scalp), tinea capitis, secondary syphilis, and pseudopelade. All potentially lead to permanent hair loss; therefore, direct and timely diagnostic information that only a biopsy can provide is essential.

Fungal origin was unlikely for several reasons. Such a diagnosis would be distinctly unusual in a Caucasian woman of this age, particularly since no source (child, spouse, or pet) was identified. The lack of epidermal changes (scale or other broken skin), edema, or adenopathy was a key factor in that regard as well.

In this and most such cases, a 4-mm punch biopsy is taken from the (presumably) active margin of the radially expanding pathologic process; biopsy of the centers would likely only show scar. The biopsy should include at least a few hair shafts, with care taken to penetrate the skin at the same angle from which the hairs emerge. This facilitates collection of the length of the shaft, which could provide valuable diagnostic information.

Done under local anesthesia with lidocaine/epinephrine, the defect is almost always closed with surface sutures, for hemostasis and to speed healing. If one felt strongly about the possibility of infection, an additional sample could be taken and submitted for bacterial and fungal cultures; in this case, neither was suspected.

The results in this case proved the diagnosis of pseudopelade, an inflammatory condition of unknown origin, possibly representing the end-point of either discoid lupus or lichen planopilaris. In any case, the other potential causes of scarring alopecia were ruled out, and appropriate treatment (perilesional injection of 5 mg per cc triamcinolone suspension, oral minocycline 100 mg bid, and topical betamethasone foam) were instituted and follow-up arranged.